Objective: To assess and compare the quality of life (QoL) in patients with schizophrenia with apparently normal controls.Materials and Methods: A secondary data analysis of a cross-sectional study that was carried out in the outpatient psychiatry clinics at a South Indian referral center. Thirty consecutive patients and 30 apparently normal individuals fulfilling the inclusion and exclusion criteria formed the study group. Demographic data for the study population were collected. Schizophrenia was diagnosed as per criteria of the ICD-10th revision and measured using the positive and negative syndrome scale (PANSS) and general psychopathology scale. Outcome measures were measured using the World Health Organization (WHO)-QoL-brief version (BREF) instrument. The collected data were analyzed using descriptive and appropriate inferential statistics using Statistical Package for the Social Sciences (SPSS) version 17.0. P ≤ 0.05 was considered to be significant.Results: There was no significant difference in terms of demographic factors between the schizophrenic patients and controls. The QoL-WHO-BREF score of schizophrenic patients was 82.33 ± 12.34 and for controls it was 90.9 ± 8.41 (P = 0.003). The individual domains of physical and psychological spheres differed significantly between the schizophrenic patients and controls. Individual domain scores varied significantly in occupation. The PANSS positive subscore was correlated with QoL score and there was a statistical significance.Discussion: The deleterious effects of schizophrenia on QoL occur significantly. Management should be planned with this consideration to yield better outcomes.

Keywords: Psychopathology, quality of life (QoL), schizophrenia, South India, World Health Organization (WHO), brief version (BREF)

How to cite this article:Mohandoss AA. Quality of life in schizophrenic patients: Comparative study from South India. J NTR Univ Health Sci 2017;6:224-31

Schizophrenia is a chronic, debilitating mental illness often resulting in incapacitation. It affects the general health, normal functioning, personal autonomy, subjective well-being, personal life, social functioning, and the overall life satisfaction of those who are affected by this disorder. The current treatment approaches for schizophrenia aims to improve the overall adaptive/social functioning, maximizing the quality of life (QoL), prevention of relapse as well as symptomatic reversal to normal life in various physical and psychological spheres.[1]

Quality of life (QoL) is a construct that encompasses several aspects of an individual's well-being and role functioning and the extent to which he or she has access to resources and opportunities.[2] The World Health Organization (WHO) has defined QoL as “an individual's perception of life in the context and value system in which he/she lives and in relation to his/her goals, expectations, standards and concerns.”[2] The conventional primary determinants of QoL — A sense of safety, stable employment, reliable financial support, supportive family, and ambient social relations. All these determinants vary, depending on subjective or objective criteria used.[3] Though QoL has been interpreted in different ways, it is unanimously accepted as an important treatment outcome goal/measure in several major mental disorders including schizophrenia.[2]

WHO-QoL-brief version (BREF), an instrument developed by WHO, which is described as a structured, self-reported, interview is based on 26 items designed to assess an individual's QoL. It assesses patients under four domains: Physical, psychological, social, and environmental. The psychometric properties of WHO-QoL-BREF have been demonstrated to be consistent with that of the WHO-QoL-100 tool.[4] Assessment of QoL remains controversial in schizophrenic patients, clouded by the presence of varying psychotic symptoms, cognitive dysfunction as well as lack of insight. Reports have indicated that QoL measures are reliable in patients with psychosis and subjective measurement is acceptable both in terms of reliability and consistency.[5] The use of such measures has been previously validated in Indian settings too.[6] However, there is a paucity of trends of QoL measures from schizophrenic patients from South India and this study was undertaken to address this lacuna. This will also help to give a robust estimate and to assess the impact of schizophrenia on different domains of the patient's life in prevailing society. This might help us to understand, plan, and anticipate problems in these patients and in the future would help to manage and rehabilitate these patients.

Materials and Methods

Data were gathered through a single-center, noninterventional, cross-sectional, observational study by a secondary data analysis approach. The primary data were used to study the sexual dysfunction of patients on antipscyhotic medication and were presented in a zonal level meeting of the National Psychiatric Association. For the current study, the same data was used. For the primary data, the patients and controls were recruited from the psychiatry outpatient wing of a teaching institution. At the start of the study, author (AMA) was educated and calibrated by senior faculties by providing education and training for using the standardized instruments. Repeated checks by faculties ensured its continuous standardized use. The study had no invasive procedure, used standard, recommended protocols, and did not deviate from any recommended health care delivery process. Verbal and written informed consent was taken from all participants. Also, the confidentiality of patients was ensured at all stages of the primary data collection. Immediately after the data collection, the personal identifiers were removed from the database. For the present study, data with no identifiers were used.

Thirty consecutive outpatients with schizophrenia attending the hospital between August 1, 2013 and September 30, 2013 fulfilling the inclusion and exclusion criteria were recruited for this study. Inclusion criteria for the study were as follows:

Diagnosed with schizophrenia according to the diagnostic criteria of ICD10;

Between 18 years and 60 years of age;

Having received adequate doses of the same antipsychotic drugs for at least 3 months;

No history of hospitalization, exacerbation, or electroconvulsive therapy application within the last 3 months;

Enough intellectual capacity to answer the scale questions and interact with the interviewer.

Exclusion criteria are the following:

History of alcohol and/or drug addiction or abuse;

Unwilling patients and those who were not in a position to give voluntary consent;

With any other systemic diseases.

Those with irregular treatment-seeking behavior; and

Newly diagnosed patients.

Gender, age group, and educational status were matched as far possible with the controls. Apparently normal and healthy controls were drawn from the normal public visiting the hospital [as attendees of patients in other departments]. Care was ensured to recruit these controls from willing persons fulfilling the inclusion and exclusion criteria except for inclusion criteria 1 and 3. Those in the control population who had their first- or second-degree relative suffering from any psychiatric disorders were excluded from this study.

From all potential participants, a preformatted, semi-structured data collection form for each patient was earlier filled out by a single author (AMA). Details of the sociodemographic information and disease status (for schizophrenics) were collected. The following predictor variables were used. Age was categorized as: i. below the 3rd decade of life, ii. 4th decade of life, iii. 5th decade of life, and iv. 6th decade of life. Education, income, and occupation were classified as per updated Kuppuswamy's socioeconomic scale.[7] Familial setup (joint/nuclear) and marital status (single/married/separated/divorced) were the other parameters used. Clinical severity of the disease was evaluated using the established norms. For this current study, the following forms were translated to the regional language using the standard, prescribed WHO methodology.[8] The positive and negative syndrome scale (PANSS-positive/PANSS-negative)[9] and general psychopathology scale [10] were used to measure details of the disease in schizophrenic patients.

WHO-QoL-BREF [11] (Tamil version) formed the outcome measure tool to collect the QoL of schizophrenic patients. This instrument considers four domains with six items each for physical, psychological, social, and environmental domains and two items from the overall QoL and one in general health. The scale is much similar to Likert with each structural rating done from 1 to 5. The instrument was translated into Tamil after a series of translations and back-translations. The Tamil version was used after equivalence was established as per standard methodology.[8] Both the raw score and the transformed score of the domains were used. Total score of WHO-BREF was considered as the overall score and used in this study. The higher the score, the better the QoL.

Statistical analysis

Data were entered and analyzed using the Statistical Package for Social Service 17.0. (SPSS-IBM, IL, USA). Descriptive statistics were provided for the numeric and categorical variables using mean, standard deviation (with prefix ±), and percent distribution (%) as necessary. Group differences were determined using chi-square (χ2) test for categorical variables and Student's t-test for continuous variables. Cross-tabulation and the chi-square tests were performed. Kruskal–Wallis test was used to determine the overall significant differences among groups. Overall significant differences were analyzed for the presence of pairwise difference using the Mann–Whitney U-test. Wilcoxon signed-rank test was used to assess the distribution of two paired variables in two related samples. A P value of less than 0.05 was used for statistical significance.

Result

The demographic characters of the study population are depicted in [Table 1]. Genderwise, there was an equal distribution among the schizophrenics and controls. The mean age of the schizophrenic and control groups were 38.53 ± 8.33 years and 35.83 ± 7.22 years, respectively, and there was no statistically significant difference (P = 0.328). The age, age group, religion, education, occupation, income, familial setup, or marital status did not significantly differ between the study groups. The mean duration of illness was 87.53 months for schizophrenics and the duration of treatment was 69.97 months. Among schizophrenics, risperidone (12 patients, 40%), haloperidol (10 patients, 33.33%), chlorpromazine (5 patients, 16.67%), and triflurperazine (3 patients, 10%) were the predominant drugs used for the treatment.

Among the schizophrenics, the mean PANSS-positive score was 9.33 ± 3.98 (7 to 22) and PANSS-negative score was 8.8 ± 3.37 (7 to 25) while general psychopathology score was 18.63 ± 3.14 (16 to 28). The PANSS-positive, -negative, and general psychopathology scores did not significantly differ among schizophrenic patients in terms of gender, age group, religion, education, income, and familial structure (P ≥ 0.05).

On comparing the domain raw score, the mean physical and psychological domain raw scores for Schizophrenia were 22.6 ± 4.39 and 18.2 ± 3.41, respectively, while among the controls these were 25.80 ± 2.67 and 20.27 ± 1.7, respectively. The differences between them were statistically significant. In the mean social domain raw score, there was a difference noted with a borderline significance (P = 0.055) while the mean environment raw score was not significant [Table 2]. The mean transformed score was statistically different between the physical domain (schizophrenia 55.8 ± 15.65 and controls 67.23 ± 9.6) and psychological domain. Similar to the raw score, a borderline significance was noted between the schizophrenics and normal controls in the social domain. The mean overall WHO-BREF score for schizophrenics was 82.33 ± 12.34 while for controls, it was 90.90 ± 8.41. The difference between them was statistically significant (P = 0.003) [Table 3].

The duration of illness and treatment duration had no significant relation with the total WHO-BREF score. For duration of illness, ρ was −0.030 (P = 0.875) and for the treatment duration it was −0.075 (P = 0.693). On comparing the duration of treatment (≥36 months and <36 months), there was no significant correlation.

On comparing the demographic factors and domain scores, the age group, gender, religion, education, income, and marital status did not statistically differ among the groups. [Table 4] depicts the P value between the domains, overall score, and the groups. Occupation exhibited significant difference in the physical domain, environment domain, and overall score [Table 4]. On correlating the PANNS-positive,-negative, and general psychopathology scales, it was observed that raw score was negatively correlated (ρ = −0.563) with the physical domain and general psychopathology was related to the psychological domain raw scores. The transformed score of the psychological domain correlated negatively (ρ = -0.449) with a statistical significance. The overall WHO-BREF score was negatively correlated (ρ = −0.459, P = 0.011) with the PANNS-positive scale [Table 5].

The current treatment protocol for schizophrenia calls for improvement of patients' adaptive and social functionings, maximization of QoL, and prevention of future relapse while concentrating on symptomatic recovery. It is also documented that in schizophrenics, subjective QoL can be a reliable marker of objective QoL.[6] In known schizophrenics, a sense of self, satisfaction with daily activities, and activity levels contribute significantly toward their subjective perception of QoL.[12]

It has been documented in the literature that the familial/societal acceptance and overall progress of schizophrenic patients is better in developing countries owing to more involvement of the family with patients and less chance of institutionalization.[13] This is also reflected by better employability in the present study population. In the present cohort, only 10% were unemployed. A similar trend was reported among the North Indian schizophrenic population as reported by Solanaki et al. where 29.8% of unemployment was observed.[14]

[Table 2] and [Table 3] highlight that the QoL of schizophrenics is relatively improved than that of apparently normal healthy controls. On QoL scores, schizophrenic patients had lowest scores in the raw social relationship domain. It has been documented that patients suffering from chronic mental illness have a strong dislike for the associated stigma owing to which they exclude themselves from normal social life. Still, there is a high prevalence of formal and informal discriminations by society/community. This is in accordance with the study of Solanki et al.[14] Such marginalized people often withdraw and or react by lowering their social interaction and or expectation as reflected by poor social scores. Hence, the difference of the mean was lowest in the social domain. Additionally, the presence of negative symptoms such as asociality, avolition, and apathy were seen in patients similar to Solanki et al.[14],[15] and Gupta et al.[16]

As observed in [Table 4], occupation had a significant relationship with the social relationship domain of QoL. This indicates that occupation may provide the social comfort to the schizophrenics better than to the normal controls. Our study is consistent with Solanki et al.,[14],[15] and this can probably be explained by the aspiration of the patients to live and earn like “normal people” so as to have a normal social relationship as explained earlier.[14] There was no significant relation between QoL with personal income as well with the social relationship domain that was in contradiction to a previous study from India.[14] This was probably due to the difference in the method of income collection. Previous studies collected the whole family income, whereas the present study collected the personal income of the patients. Similarly, the duration of illness and treatment had no correlation with QoL or its domain.

PANSS-positive scores were significantly correlated in negative direction with the physical domain and total QoL [Table 5], which were similar to the result of Solanki et al.[14] On the contrary, there was no significant correlation in the PANSS-negative scale. The general psychopathology subscale had a significant negative correlation with the psychological domain only. In contradiction to pertinent literature,[14] only certain domains appear to contribute to the difference in the QoL. This could be due to an inherent difference in the study population or owing to the factor that the present population was under active treatment for varying time periods with a significant number of them having ≥5 years of active treatment, leading to stabilization of symptoms in individual domains. However, the present study is in line with the study of Galletly et al.[17] and Heslegrave et al.[18] who demonstrated that changes in QoL among schizophrenics were highly related to general psychopathology. The results of the present study implies that in spite of regular, continuous treatment, overall levels of general psychopathology are more related to QoL than PANNS-positive and -negative scales. It must be recollected that the scale of general psychopathology contains items with questions related to symptoms of depression and anxiety. It is probable that anxiety and depression cloud the other cardinal features of schizophrenia. As cited in the literature [1],[14] this correlation could give a direction for future schizophrenic research.

The duration of treatment in schizophrenics (cutoff: 36 months) did not cause any statistically significant difference. However, the group with <36 months of treatment had lower scores than the group with ≥36 months of treatment. Considering the overall WHO-BREF score in the schizophrenia group, as predicted, lowering of expectations in all spheres seems to be a viable mechanism through which schizophrenics cope with living in the community. They do so to maintain their self-esteem and perceived subjective well-being. As per the literature, subjectively assessed QoL of schizophrenics is significantly lower than that of healthy controls while when assessed by quantitative scales, they exhibit a significant difference.[19] A certain study also indicates that such an effort reveals no difference as compared to the general population.[20] In tune with the present results, many previous researches could not find a statistically significant correlation between positive schizophrenia symptoms and QoL. Hence, our results are not in isolation [21] and could be related to the outcome of the disease.

The outcome of the present study should be considered under the following dire situations that could have potentially clouded our observations:

The present study is based on a tertiary, general hospital outpatient sample and is not representative of the entire schizophrenic community in this region.

Hospital admission or Berksonian bias cannot be ruled out. All major limitations of a secondary data analysis could be applicable to this study too.

The duration of illness is long, which could have potentially rendered the sample heterogeneous in spite of our best efforts to make the cohort homogenous. Acute illness or exacerbations (within the past 3 months) were not included to avoid this feature.

The QoL instrument WHO-BREF was not designed specifically for South Indians or schizophrenic patients.

Variables were assessed cross-sectionally. Hence, the cause-effect relationship between variables and QoL or its contributory nature cannot be assumed on face value. Longitudinal studies are advised for verifying the results of this study.

The sample size could be regarded as small and hence, generalization of the present findings for all types of patients is not possible.

It is documented that Indians give much priority to peace of mind and spiritual satisfaction over physical and psychological functionings. This factor could alter the perception of QoL.[22]

The controls were drawn from attendants of patients attending the hospital for other ailments. Though it can be presumed that the cultural, social, economic, and religious affiliations of the controls were the same, in reality they may have been different, there by potentially contributing to altered QoL scores.

Being an explorative study and a secondary data analysis, the sample size and power calculation were not undertaken. Longitudinal studies should be undertaken with a larger sample size to validate the results of the present study.

Conclusions

To the best of our knowledge, this is the first pilot effort to document QoL among schizophrenics in this part of the world. The present study using a well-defined cohort confirms that:

There is a relatively poor QoL for schizophrenics as compared to normal individuals in spite of the long term of pharmacological treatment.

Chronic schizophrenic patients require more attention in physical and social domains too.

Certain factors influencing QoL are not changeable; those that can be changed need to be identified. Effective management of these factors would improve the QoL of these patients.

WHO-BREF construct can be used to periodically evaluate the treatment efficiency for targeted interventions and create more specific measures of response to treatment.

The study also underlines the need for India-specific QoL BREF questionnaire, given the consideration of our locoregional and cultural aspects.

Acknowledgement

The author wishes to thank Dr. S. John Xavier Sugadev, Assistant Professor, Department of Psychiatry, Madurai Medical College, Panagal Road, Madurai-625020 and all other staff at the department for their support, encouragement, and timely corrections. The help of all the subjects of the study is acknoweldged.